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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CommNrs: AJd:n' frobei is O:J S+ae f �equ: P#d an Weeder SERVICE REQUEST II rpownienconce12-107 BUSINESS NAME ,t,,,,_ lit. S' A o o,S` f 7e2 - OWNER / OPERATOR HOME or MAIuNo ADDRESS . CHECK if Ba.uNOADDRESS13 FACLLITY NAME 6a r d 1 (1/6) 67f 1317 SITE ADDRESS 12. v G/ I=ran K W tS t C t rc/r- Amount Paid 3 y s; po S rCPCKtd e% 95206 I Invoice # Nan" City Zia CO& HOME or MALINti ADDRESS (N Different from Site Address) K 3"M Numbu CITY Sa C � M QniV STATE Ca. ZIP J PHONE #i Ev.N AP# LAND USE APPLICATION # (U) 306 3767 ! q 3 --33 &0- 3h PHONIER Exr• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CommNrs: AJd:n' frobei is O:J S+ae f �equ: P#d an Weeder QrQ w^ CHECK if BILLING ADDRESS BUSINESS NAME ,t,,,,_ lit. EMPLOYEE#: 02 ZJ '6 p W HOME or MAIuNo ADDRESS FAx I 010 &OIJ c d-+ t%'v o Date Service Completed (if aiready completed): 1 (1/6) 67f 1317 CITY STATE Ca ZIP a rl 70 BILLING ACKNOWLEDGEMENT : I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE EDERAL laws. APPLICANT'S SIGNATURE' DATE: y Lit, 110 PaortRTY / BUsmxss owxeR ❑ OPERATOR/ MANAGER (3 OTHER AoTHOMZIED AGENT Cr Ccn*-4% c.10r If APPLICANT is not the BILLING PARTY proof of authorization to sign is required rifle AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: CommNrs: AJd:n' frobei is O:J S+ae f �equ: P#d an Weeder T4nx5 CAST) ac- Inv4*%14r!' . GDI EGEI Qmst *o f eAsr•• -rk:s ;n1`h�► lla y on. �R20 SAN JOAOVI ACCEPTED BY: U (L EMPLOYEE#: 02 ZJ DATE: tC DE ASSIGNED TO: EMPLOYEE #: -9/7 DATE: f/ ZD Date Service Completed (if aiready completed): SERWA CODE: PIE: y Fee Amount: 3y5 -. OW Amount Paid 3 y s; po Payment Date � Jb�l L7 Payment TypeCAJ.it Gpd I Invoice # Check # Received By: EHO 48.42-025 �n� a 'On �J ©� SR FORM (Golden Rod) REVISED 11/17/2003 J COUNN JIENTAL )AMEW